“Multigenerational Poverty”

I was taught in medical school that poverty is the cause of our difficulties in providing medical care. I was taught to blame the patient for being poor and unemployed.

Since they were poor, they had no voices.

“They don’t know any better,” I was told.

I trained to be a physician at New Orleans Charity Hospital from 1979 through 1985.

“Why didn’t she come in before her foot was gangrenous?” I asked. We had to do an emergency amputation of a woman’s foot.

“Multigenerational poverty.”

We shook our heads and clucked our tongues behind blue paper masks as her foot thumped into the stainless steel bucket. We all knew she wouldn’t take care of her diabetes. She’d be back for us to take off the leg. We knew there was nothing we could do about it. She wouldn’t come back till she was desperate again.

But there was no care for her except emergency care, no options for her to get across town to crowded student-staffed medical clinics.

“Emergency” care meant waiting in a packed concrete room for hours and days to be triaged into care by students.

I didn’t feel too bad about being a doctor for these people, even though I was only a student.

“If it were not me, they’d have no doctor at all,” I thought.

As a student in a rural satellite hospital, I delivered pre-term and stillborn babies from women who had no prenatal care. On the wards at the “Big Charity”, I stayed up at night hanging IV bags so they wouldn’t run dry. I came in early to be sure my patient in heart failure got her diuretic tablet. I hoarded syringes so I would have them to draw blood from my patients.

And the nurses cared. There simply weren’t enough of them to do the work.

Crowded outpatient medical clinics were venues for students to write prescriptions. Treatment was pills. There was nothing else to offer.

We all cared.

I cared a lot.

But there was nothing else I could do but show up each day and shovel the ocean with my prescription-pad teaspoon. There was barely time to use the bathroom.

When I moved to Oregon in 1985, I felt like I had moved to heaven. People had access to medical care. The state still funded medical education. There was a two-tiered system between the private and the publicly funded, but there was care.

“Managed care” corporations moved into Oregon during the early nineties with promises of cost efficiencies. Drugs were promoted as the accessible alternative to other treatments.

As a physician, I was told to “get on the wagon or be left behind.” I worried aloud to deaf ears. People had kids and payments. They feared being left behind.

I stayed off the managed care wagon.

I was left behind.

Private practice medical care was replaced by fast prescription writing performed by employees of managed care corporations. Even the non-profits have been forced to adopt this “treatment model”.

Through good and bad times, there was a steady stream of budget cuts for all medical care and education. Hospitals closed. Clinics shut down. Medical education dollars evaporated. Non-pharmaceutical care options vanished as “cost efficiencies” were ruthlessly pursued.

Generous pharmaceutical companies helped by funding medical research and doctor training. They provided supplies of pill “samples” to be used to treat poor people while they awaited access to disability insurance treatment dollars.

When I left Oregon last year, the standard of care for most had been lowered to 1980’s Charity hospital. Even private insurance venues are staffed by trainees wielding prescription pads. Medical students and nursing students come cheap.

Over twenty-five years, through good economic times and bad, the pool of “have-nots” became an ocean in Oregon. Non-drug treatments were removed.

There’s not much left but high-profit pills and emergency rooms.

In 2004 I went to work in a crisis clinic for high-need, low-resource people. My mandate was to write prescriptions to keep people out of expensive hospitals and bridge patients to other care providers.

But there is no one else.

They’ve been cut.

“Why did he wait till it got so bad?”

“The homeless. The poor. They don’t know any better.”

Last year I came to Santa Cruz county in the financially struggling State of California.

California is later in this process than Oregon, much like Oregon was later in this process than Louisiana when I moved there.

There is a new “initiative” right now to move health care dollars into “prevention” as a “cost-savings” maneuver. These are lovely words. But this could cut out care for those that are already ill. This could cut out payment for non-pill treatments.

Because we are in a tough economy, it’s an easier sale to make.

With the DSM V, the psychiatric pharmaceutical companies are expanding their market from people who are sick, and have less insurance money to grab, into the arena of the healthy who still have insurance dollars.

The same thing is happening in all areas of medicine. We are supposed to call this “preventative care”.

The practice of medicine in our country is being swallowed whole by a snake. The snake started with the poor, the black, the brown; the already disenfranchised of the deep south and inner cities many years ago. It was an easy sell to the better-off taxpayers. Who wants to give up money to take care of poor people?

Medical corporations now ride the wave of financial distress to expand into mainstream suburban populations who have been protected in the past by their cushions of monetary success.

As people lose jobs with insurance benefits and access to health care, we’re still being told it’s their own fault for being so unemployed, under-employed and poor.

Necessary Phoenix: Can one physician help heal the practice of medicine? After two and a half decades of work as a psychiatrist in private practice, community clinics and inpatient units, Dr. Keys shares her personal perspectives on the devolution of medical care and the needed resurrection.

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26 COMMENTS

I feel like an intellectual have-not reading this, because I have no idea what you are trying to say. What does “multigenerational poverty” have to do with marketing psychiatric pills have to do with managed care?

Answer me this: is the problem with psychiatry too much treatment or not enough treatment? Moreover, does America need more government funding to set up extensive mental health clinics in urban and rural areas afflicted with lower employment rates?

Emily,
Thanks for reading and replying. Sorry if I’ve missed the mark for you. You ask some great questions.

“Multigenerational poverty” and lack of money was/is used as an excuse to market “meds only” treatment in every part of medicine. I was taught that when medical care failed, it was not because medical care was lacking in any fundamental way, but because the patients were lacking somehow: being “non-compliant” and taking bad care of themselves.

In essence, I was taught to blame the victim when they only came in for care when things had reached emergency critical proportions.

The latest marketing of all drugs, including psychiatric drugs, is that we physicians need to “treat” people that do not yet have an illness with pills to “prevent” the possible onset of illness i.e. cholesterol lowering drugs to “prevent” coronary artery disease because the patient cannot be counted on to make pro-active life changes toward health. Cholesterol lowering medicine have never been shown to prevent anything in an otherwise healthy person.

being a “golden oldie”, I know exactly what you are talking about.I remember well the days when our family doctor was a caring friend and didn’t mind popping in if one of the children wasn’t feeling well. Had such a GP been around when my son collapsed delirious because of a badly infected toe, he would have never ended up in psychiatric care, drugged with antipsychotics and labelled mentally ill. I can remember the days when the same doctors and nurses looked after you if you ended up in hospital. They had time to talk to you. You didn’t have to wait for hours in A&E either.Hospitals were small friendly places, not huge technical monstrosities. Doctors are much better payed nowadays but I am not so sure about their job satisfaction. It has all turned into an impersonal rat-race and can technology and fancy drugs compensate for a friendly, human approach?

Multi-generational poverty is a problem. The over prescribing of harmful psych medication to the poorest members of society exacerbates that problem. Doctors of all stripes write prescriptions for dangerous psych drugs for the poor at a much higher rate than in higher income populations. Poverty stricken children on Medicaid who already suffer under the weight of circumstance are prescribed anti-psychotics at 4x the rate of their middle class counterparts. Doctors may be given a mandate but they do have a choice to not prescribe harmful drugs to such vulnerable populations. Doctors have agency. Doctors should have the capacity for critical thought. They can choose to do no harm. Anyone who prescribes these toxic meds to people who are already floundering under the misguided notion that they are providing care or at least doing something should seriously reevaluate. Better to spend your energies staffing a soup kitchen. I have asked this question before in response to your blogs, where is the personal responsibility? To change the world, we must first change ourselves and our actions.

Hey Ruby,
I’m glad to see you’re still around the MIA to greet me on my first return blog. You have a good way with words and raise some good points.

I agee. Multigeneraltional poverty is a problem. I don’t like to see poverty or unemployment being used as an excuse for poor health care. Good health care should be available equally to all without regard to their employment or finanacial status.

This article is a frightening reminder of what could, and may well, happen to health and social care in the UK. The government has opened up the NHS to private health care providers, in large part due to pressure from USA health insurance companies, and cut many services which many disabled and poor people rely on for a basic quality of life.

Although we have drug based psychiatric care with all the problems that brings as I understand it things are much worse in the USA.

In profit driven system it is much easier for drug companies to push drugs and cut preventative services (such as good diabetes care) or services which really address the problems. It is hard for health care providers to make money out of chronic conditions so preventative work is not funded as well as it needs to be. We are seeing this in the UK right now with social services and benefits being cut. People are likely to become anxious and depressed, many will go to their GP’s and then be prescribed anti-depressants and anti-anxiety pills.

I think your point about DSM 5 is very interesting. In the UK I hear people going on about preventative psychiatry, they don’t say what they mean by it, but when I ask questions about addressing racism, reducing child sexual assault or family violence or providing services aimed at people surviving these traumas I get blank looks. So whatever they are planning my guess is it is more about selling even more pills than actually addressing people’s real problems.

To change the world we need to organise and campaign, but before we do that we need to be educated about the causes of our problems, and this article does just that.

I have watched management corporations chew through health care systems in Oregon for two decades now. The timing is different in different locations. The poorest people have least voice so they go first. It’s taken a while for the chomping jaws to make it around to the better-off layers of communities.

Where I am right now has had a lot of budget and program cuts but, I am told, hasn’t been stripped down to the bare bones of medication as the treatment for everything yet. These look like temporary budget cuts in a bad economy. There’s a lot of denial.

I doubt that “Preventative” medical care will be excericise programs, talk therapy or life changes. It will be pills.

Your comment, “As people lose jobs with insurance benefits and access to health care, we’re still being told it’s their own fault for being so unemployed, under-employed and poor,” is very telling. While we have a state funded healthcare system in the UK, though it is under threat, we have a recession and cuts to services. A lot of government rhetoric is about blaming the poor to justify the cuts to benefits and services. Yet poverty is associated with bad health and high rates of mental health problems.

So from the cuts to benefits and services we can expect more health and mental health problems. As I said before our psychiatric services are not as bad, in terms of drug prescribing, as the USA, though they are still based on tranquillisers, with all the problems and neglect for people who are severely mentally distressed. So my prediction is that there will be a rise in those who suffer state and private company sponsored tranquillising and neglect in the UK as these policies take hold.

I wonder what the poor of New Orleans are doing now? Charity was never reopened after Katrina. Politicians in New Orleans have made a concerted effort against the poor and Katrina helped them do so. It is disgusting.

At one time I was a hospital chaplain. I did my clinical pastoral training in the university medical center of the state where I now live. This was in 1988. The Med Center was seen as the “state” medical hospital for the state, although the Med Center hated that reputation. I saw the same things that you describe about what took place at Charity. We serviced the poorest of the poor from the Mississippi Delta region, one of the poorest places in the United States. The doctors were continually blaming the people sent to the med center for their problems. But at least they treated them and took care of them.

Zip ahead to 2012. The very same university med center ditched it’s “state hospital” designation and now wants to treat the rich that fly in from foreign countries. It’s extremely difficult to get in their doors if you’re poor and without health insurance. But rich people from foreign countries are always being jetted in each and every day. I don’t have health insurance but needed medical attention for a heart attack. They demanded $104 in cash up front just to sit in their waiting room. They wanted another $154 dollars for the director of the cardiac clinic. They didn’t want any money for the actual intern doctor who met with me but they wanted me to pay $154 to the director who never even saw me. All he did was choose the doctor from a list who would be the one to deal with me. That doctor wanted me to have an ultrasound of my heart. When I sat down with the person who arranged such things she stated that she needed $400 cash from me then and there. When I told her that the ultrasound must be some fancy test to be that expensive she informed me that this was my downpayment since I didn’t have insurance. The Test itself costs $4,000! I laughed, wished her a good afternoon, and left. Things have changed a great deal at the wonderful University of _______ Medical Center! So, this confirms exactly what you wrote about.

You brind up a really interesting point about why the DSM is expanding into the sector of people who have health insurance. I never thought of that before. You are right, our health care system is being swallowed by a huge and very insidious snake. How do you think the Affordable Health Care Act will affect all of this?

Stephen,
Thanks for reading and sharing your thoughts here. I appreciate you’re validation of my observations of the history and changes in health care.

I’m skeptical of the Affordable Health Care Act and will wait and see how it pans out. So far it’s boosted the premiums of my $4000 deductable insurance to “add” a few scraps of “well women’s health coverage” we already had. I count myself lucky to have insurance at all and do everything in my power to neither use it nor lose it.

I have talked to people who are trapped in unhappy work, unhappy realtionships, unhappy locations because they are held hostage by health insurance. They can’t leave without losing access thay may never be able to re-gain. I know people who are impoverished by insurance premiums. These are the lucky “haves”.

Then there’s everyone else, the uninsured without access to medical care.

“Affordable Health Care” can only work when the for-profit insurance corporations are removed from the picture and all care is delivered through one equal single payer system with everyone in one risk bucket. Insurance works by averaging risks among high and low risk people. If you “cherry pick” the healthy young ones and put them in a separate low-risk category and keep out anyone with a “pre-exsisting” condition you apear to lower costs (and you REALLY increase profits), But you kill the whole principal of shared risk in the process. This is one reason why early “managed care” plans seemed to work so well. They sold these plans to companies with young healthy worker populations.

For UK readers, and those in the USA who have the time and interest I recommend reading, NHS PLC – The Privatisation of Our Healthcare by Allyson M Pollock, a professor of Health Policy at University College London. She makes many of the same points as Alice does here, ie that shared risk makes it affordable for all of us to have expensive treatments when we need them and that privatisation makes that increasingly difficult.

Private healthcare is not good for the poor but neither is it good for the moderately well off.

My inspiration for this piece came from a recent re-read of John Steinbeck’s “Grapes of Wrath”. Not much has changed in the tactics of Corporations since the 193o’s when the small farms of our country were turned into massive agri-business.

The Grapes of Wrath was set in the Great Depression, the last major crisis in capitalism. Out of it came the world bank and various laws and economic principles which were supposed to stop the banking crisis which we saw in 2008. But these laws were slowly eroded as the banks and corporations used their wealth to lobby government and influence the people using PR and advertising.

It wasn’t until the banking crisis that I really understood the link between poorly regulated capitalism and the dominance of the medical model of mental distress and the way these dangerous and not very effective drugs are pushed so widely.

John,
You sum it up so much more clearly than I can. From what I’ve been able to gather with regard to the 2008 banking crisis, much of the banking crisis came from unregulated financial institutions, the “shadow banking” industry. This “shadow banking” industry vanished very quickly, as did the money invested in it.